A "List of Covered Drugs" is also known as a Formulary. The prescription drugs on this list are selected by the plan in consultation with a team of physicians and pharmacists who represent the prescription therapies believed to be part of a quality treatment program. This Formulary list includes both brand-name and generic drugs, and must meet the requirements set by Medicare. Medicare has approved the plan's drug list.
The Formulary or drug list includes both brand-name and generic drugs. A generic drug is a prescription drug that has the same active ingredients as the brand-name drug. Generally it works just as well as the brand-name drug, but costs less. There are generic drug substitutes available for many brand-name drugs.
To search for your covered prescription drugs, you have the following options.
You may locate drugs by name in the Online Formulary Search Tool. You can search for your prescribed medications by the name of the drug, therapeutic category, or drug class.
A list of the most commonly prescribed medications is also available. Select from the options below.
A complete list of covered prescription drugs is available. Select from the options below.
The plan does not cover all prescription drugs. In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more information about this, refer to your Evidence of Coverage, in Chapter 5). In other cases, we have decided not to include a particular drug on the drug list if another comparable drug is available on our Formulary.
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these requirements to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which makes your drug coverage more affordable.
In general, our rules encourage you to get a drug that is safe and works for your medical condition. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.
Memorial Hermann Advantage requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescription(s). If you don't get approval, Memorial Hermann Advantage may not cover the drug.
In some cases, Memorial Hermann Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Memorial Hermann Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.
In most cases, your prescription drugs are filled at Memorial Hermann Advantage's network of pharmacies. A network pharmacy is a pharmacy that has a contract with the plan to provide your covered Medicare Part D prescription drugs. To verify if a pharmacy is part of our network, please contact Customer Service at (844) 860-6750 (TTY 711). You can also download a copy of our 2020 Pharmacy Directory or visit our website's online pharmacy search tool.
To obtain prescription drugs by mail, use the following mail-order form or call our Pharmacy Member Services at (866) 909-5170 (TTY 711), Monday through Thursday, 24 hours a day, 7 days a week, Fridays from 12:00 a.m. to 9:00 p.m. CST, Saturdays from 7:00 a.m. to 3:30 p.m. CST, and Sundays from 9:00 p.m. to 12 a.m. CST. Prescription drugs that you get through any other mail order service are not covered.
You can use the mail order service to fill prescriptions for many drugs that are on the formulary list. When you order prescription drugs by mail, you may order up to a 90-day supply of the drug.
Generally, if you are taking a drug on our Formulary that was covered at the beginning of the year, we will not discontinue the drug or add new restrictions during the covered year except when a new, less-expensive generic drug becomes available, or if new information about the safety or effectiveness of a drug is released. Most of the changes in drug coverage happen at the beginning of each year (January 1). The Formulary may change during the year for the following reasons:
These changes to our Formulary are updated monthly; and updates are provided with a monthly Formulary Addendum. If your drug has these additional restrictions or limits, you can ask Memorial Hermann Advantage to make an exception to our coverage rules.
If a change impacts your current drug regimen, we will notify you of the Formulary change at least 30 days before the date that the change becomes effective. Your doctor will also be informed about this change, and we can work with you to find another drug for your condition. However, if the Food and Drug Administration (FDA) deems a drug on our Formulary to be unsafe, if the drug's manufacturer removes the drug from the market, or if a new generic drug replaces a brand name drug on the Drug List, we will immediately remove the drug from the Formulary and provide notice to members who take the drug. In nearly all cases, we must get Medicare approval for changes made to the Formulary.